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Monday, April 25, 2011

Let GPs handle the poor, and polyclinics the elderly

A DECADE ago, the Ministry of Health (MOH) introduced a scheme for elderly patients that allows them to see a general practitioner (GP) in a private clinic, but still pay subsidised po-lyclinic rates.

The idea was to allow the elderly to see a doctor near their home, instead of having to travel to a polyclinic when sick.

It took off slowly, since not many of the doctors running the 1,600 GP clinics wanted to look after such patients. Reasons cited were paper work involved in getting payment from the ministry, and having to prescribe cheaper generic medicines for these patients, similar to those at polyclinics.

However, there are now about 200 GP clinics on this Primary Care Partnership Scheme (PCPS). Last year, 32,000 eligible patients made more than 70,000 visits under the scheme. It appears to be working well, and now would be a good time to expand it to take in more people.

Currently, it is restricted to people aged 65 and older, coming from homes with incomes that place them in the bottom 30 per cent of families - in other words, a per capita income of $800 a month. The disabled from a similar income bracket, and those who are unable to work due to old age, illness or disability and who are thus receiving Public Assistance, are also eligible.

But why restrict it to the elderly and the disabled? There are good reasons to expand it to treat low-income patients across all age groups. This would then free up polyclinics to take care of another category of patients: those with chronic illnesses.

For a start, PCPS can be extended to the family members of an elderly person who is on the scheme. After all, the task of certifying the family income has already been done.

The programme can later be extended to others who fall within that income bracket. This allows low-income patients easy access to affordable health care near their homes. They can also get treatment at night, when polyclinics are closed.

This would also give a boost to neighbourhood GP clinics, which have been complaining of dwindling patient numbers as patients turn to polyclinics or hospital specialist clinics which offer subsidised care. This was raised in Parliament some years back, when it was revealed that more than half of GPs provide aesthetic treatments to bolster their income.

Letting them treat subsidised patients should boost their revenue, and keep the doctors focused on practising mainstream medicine.

Channelling low-income patients to these GP clinics will also give a breather to polyclinics, which have seen their workload go up significantly in the past decade.

In 2000, the 18 polyclinics had a combined number of 2.7 million consultations. Last year, it was 4.3 million - a jump of 1.6 million consultations.

One major reason for the huge, 60 per cent jump in numbers is the changing profile of polyclinic patients. Polyclinics were set up to care for the bottom 20 per cent. Once the bastion of the poor, they are increasingly becoming the bulwark for elderly people with chronic ailments.

In the past, most patients who went to the polyclinics were there for flu and diarrhoea. Today, three of the top four problems seen at polyclinics are high blood pressure, high cholesterol levels and diabetes. These are all chronic ailments which require ongoing care.

Polyclinics have seen the number of patients with these chronic problems go up by 4 to 5 per cent a year. Today, they look after 470,000 such patients.

Many patients with chronic ailments are older, and either have little income or are not working. Cost is a big consideration, which explains why many go to polyclinics which have subsidised rates.

A Singaporean patient over the age of 65 pays $5.20 for consultation at a polyclinic, and only 70 cents for a week's supply of each type of subsidised medicine. These are prices no GP can compete with.

These patients also get very good care at polyclinics. Perennial complaints about long waiting times are being tackled. They are now given appointments so the wait is shorter. For better continuity of care, the polyclinic tries to assign repeat patients to the same doctor, instead of whichever doctor is available.

Unlike neighbourhood doctors who practise on their own, polyclinic doctors have to follow the set of treatment guidelines drawn up by specialists. So diabetic patients all have blood tests, their feet screened and their eyes checked regularly. Polyclinics have the equipment and staff for such comprehensive care.

As a result, the number of chronically ill patients who achieve optimal results has gone up.

The National Healthcare Group, which runs half the polyclinics, reports that 42 per cent of its diabetic patients are now able to keep healthy blood sugar levels - up from just 26 per cent a decade back.

Polyclinics are fast becoming centres of excellence for treating chronic ailments, and improving.

The population is also ageing rapidly. One in five people here will be aged 65 years or older by 2030. The pool of patients with chronic diseases will grow in tandem, making it even more critical that as many as possible are well-controlled and stay out of hospitals.

It would therefore be timely for polyclinics to change their focus from treating the poor to treating the chronically ill.

It makes sense for polyclinics to ramp up their capacity to manage chronic illnesses, and let GPs take a bigger load of caring for low-income sick people with common illnesses like the cold and flu.

This would be a win-win solution for all. Low-income patients benefit because they can go to their neighbourhood GP and pay subsidised rates for care. The GPs benefit because they will see more patients and enjoy higher revenues. Polyclinics can concentrate on being centres of care for the chronically sick, who get comprehensive treatment.